Herpes concerns

Dear Doctor,

One month ago I developed a small red circular rash on my upper left cheek and my left lymph node in the neck was swollen (I remember having been kissed there in a social situation about 5 days before the small rash developed).  I went to a doctor, who believed it to be oral herpes, and I started taking acyclovir.

Two days later I started feeling itchiness in the genital area.  I am not sexually active.  I became concerned that I had transferred the herpes virus to the area myself, and had an ob-gyn examine me.  He confirmed there was a rash (no lesions) and told me to use hydrocortisone cream.

I have taken blood tests for both Type 1 and Type 2 Herpes (both the Igg and the Igm tests) and all have come back negative.  This was only two weeks after my potential exposure, however, so I am to take the tests again in another month. The doctor informs me the cheek situation would be a true primary outbreak, since I had not previously been exposed to either type. (This concerns me as far as the possibility of autoinoculation is concerned since I understand this can only easily be done during a true primary.  I also remember examining the sore closely, and quite possibly rubbing a towel after a shower on my face and then in the genital area.)

It has now been almost four weeks and the facial sore is completely gone (it scaled over very quickly and was gone within 2 weeks), and although the genital rash got better for a little while it is now back and remains itchy, with red patches, slight burning, but still no lesions. The hydrocortisone cream does not help.

Also, after I stopped taking the acyclovir I got what appeared to be a couple of small sores on my lips--but they never crusted over or scaled or anything.  Just went away in a few days.

My questions are:
1.  Does that mode of transmission (a kiss on the cheek) seem a likely way for me to have contracted herpes?  Are there any other conditions that might have had the same reaction from a kiss like that (including the lymph node swelling and the lip involvement later?)  I should note here that another doctor (yes, I am obviously concerned about this!), prescribed keflex after I had completed the acyclovir in case the infection had been something else--like staph, or impetigo--but the cheek situation had already pretty much cleared up by that time and the keflex had no affect on the genital area.  The rash remains.

2.  The most important question: How likely is it that I transferred herpes to the genital area myself?  Does it make sense that it could still be affecting me four weeks later (despite some notable improvement for awhile)?  

I am very concerned about this potential transmission, and also that, even assuming the blood work comes back positive in a month, that I won't know for sure--since obviously it can't distinguish between sites, and there are no lesions in the genital area to take a swab from.

Thanks for your help.

[Alan Rockoff, MD]

1.  Not likely.  The description is of something a whole lot milder than a true primary outbreak with no antibody protection--that causes high fever, bleeding gums, etc.  And if it's a first-attack recurrent-type lesion, you ought to have Type 1 antibodies, and you don't.  I don't know what the genital rash is, but it sure doesn't sound like herpes.

2.  Not likely for many reasons.  Basically, I don't think you have herpes at all, anywhere.  

Bottom line:  Get another herpes titer in a couple of months so you can out this behind you.  Also, see a doctor (skin, perhaps) who actually knows what herpes looks like and get as definitive an opinion as you can.  Whatever your genital rash is deserves to be treated in its won right.

Take care.

Dr. Rockoff

[train976]

Thanks for this response.

One follow-up: the doctor that originally saw the facial rash was a dermatologist (it was a red circular patch of skin, about an inch in diameter, ultimately with blisters--they crusted over in about a week).  My fever was only about 99, but my lymph nodes--left side of the neck and above the collarbone were swollen.  When I tested negative for both type 1 and 2 later that week he told me that some people have milder symptoms than others during a true primary outbreak, and also that since it was on the upper cheek (and not a mucuous membrane) that could explain the milder rash.

Is this inaccurate in your view?  Do people experiencing a true primary (that show symptoms) always have severe ones?

Thanks again.

[Alan Rockoff, MD]

I don't see enough primary attacks to comment.  It nevertheless remains the case that you are exceedingly unlikely to have spread anything from face to genitals.  Also, I bet that when you repeat the herpes 1 titers they will be negative, showing that the initial diagnosis was incorrect.  We all make mistakes.

Dr. Rockoff